Super-fast particles, propelled by 250 million volts of energy, will smash precisely into malignant tumors, scrambling them into impotency while leaving nearby cells unscathed.

The cancer-fighting benefits of the center, with its 8-foot-thick walls, will be "profound," says M.D. Anderson's literature, clearly outperforming standard X-ray radiation treatments.

Top doctors at M.D. Anderson view the center, the nation's third major proton facility, as a bold vision worthy of one of the nation's top cancer centers. But the story behind it is as complex as it is visionary, and raises significant questions about medicine, money and the free market for health care technology.

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For one, the treatment is substantially more expensive than other treatments, and its advantages have been proved on only a small number of cancers. Its value in treating others, given its cost, is openly debated among experts.

Secondly, though the new facility will say "M.D. Anderson," it will be owned by a group of private investors who stand to make — or lose — the most money. Those private investors have committed millions of dollars and include some of the biggest names in Houston, as well as the Houston firefighter and police public pension funds.

For its part, M.D. Anderson has promised to "promote" proton therapy, for which it could earn a seven-figure bonus if the investors make enough profit.

According to contracts obtained by the Houston Chronicle under the Texas Public Information Act, M.D. Anderson is contractually obligated to its venture partners to "advertise and promote" the therapy, doing things such as touting its benefits on the Internet. The proton center estimates that one-third of M.D. Anderson's patients will be suitable for the therapy.

Hospital officials downplayed the promotion provisions. They said their goal as a leader in cancer research is to prove whether proton therapy will improve treatment for various forms of cancer, as they strongly suspect it will.

"We are not promoting this in the hyped-up sense. We're going to be educating," said M.D. Anderson President Dr. John Mendelsohn.

"I'm convinced that proton therapy is at least as good as standard radiation therapy, and there are preclinical and scientific data that say it's very possible it will be better," Mendelsohn said. "And that's what Anderson is here for"

Aggressive treatments for all patients is "part of our national culture," Mendelsohn said, even if it sometimes drives up patient costs.

Addressing a problem

Protons attempt to address a tricky cancer-fighting problem. Standard X-ray radiation, called photons, can leak into surrounding tissue when it is administered and cause side effects. This sometimes limits the dose that a doctor can give, at times less than it might take to kill a tumor.

The promise of replacing photons with the heavier protons is that they don't scatter as much. Unfortunately, they require a particle accelerator of the size and expense normally found only in an advanced physics lab.

Dr. James Cox, head of M.D. Anderson's radiation-oncology division, said he wasn't sold on protons until three-dimensional body imaging such as CT scans advanced, meaning technicians can now figure out exactly how deep to drop the heavy particles with precision down to the millimeter.

"I went from being a skeptic 15 years ago to letting the science drive my decisions," said Cox, who will be the medical director of the new center.

According to studies that Cox and others have published, adult cancers of the eye, spine and base of the skull benefit from proton precision because critical organs are so close by. Children with tumors should especially benefit because regular radiation can affect their growth and cause secondary cancers later in life.

But taken together, those cancers are relatively rare, comprising perhaps 10 percent of the cancers the proton center expects to treat, according to internal financial projections obtained by the Chronicle.

The largest single cancer to be treated at the center — more than a quarter of all billings — will be prostate. And the jury of medical peers is still out on whether protons are more effective in treating that cancer.

"It's unclear just how much improvement there would be and if it justifies the cost," said Dr. Alan Pollack, chairman of the radiation-oncology department at Fox Chase Cancer Center in Philadelphia.

The trial "validates the use of proton-beam therapy," the authors wrote, but does not prove that it does any better than IMRT, which is readily available at many cancer centers.

There may be a point of diminishing returns when increasing radiation doses, doctors at Johns Hopkins University said in an adjoining editorial. Techniques such as IMRT have safely achieved what could be the optimal dose, they said, and an equally good or better treatment might turn out to be lower radiation given in tandem with hormone-suppressing drugs.

If any one treatment had fewer sexual side effects for men, a common problem in any prostate regime, that might be a major selling point.

But no study has compared protons with other forms of radiation nor reliably compared radiation with prostate-removal surgery, Cox said.

Some are doubtful it will make much difference. Supporting protons is "like saying, 'Will surgery improve if we give the surgeon a sharper scalpel?' " scoffed Schulz.

That exact analogy also is used by proton-therapy supporters. Cox is eager to explore protons for many things, such as inoperable lung cancer, for which patients often don't get the radiation dose doctors think they need because nearby tissue is too sensitive. M.D. Anderson is the perfect place to settle the academic debates, he said.

Howard Amols, president of the American Association of Physicists in Medicine, generally agreed. But he said he didn't "see a burning need" to build a proton center at Memorial Sloan-Kettering Cancer Center in New York, where he is chief of clinical physics.

He and Pollack said they considered a few nonprofit proton centers across the United States as sufficient to provide useful proton studies and receive referrals of rare cancers.

M.D. Anderson's center, however, won't be nonprofit. Indeed, it will address an institutional problem at the hospital that is as much about business as health care.

Of 12,000 M.D. Anderson patients who will need radiation this year, Cox said, only 5,000 will complete their multiweek course of treatments at M.D. Anderson. The rest go back home for convenience, generally out of town. Cox sees this as a health issue because he thinks his department can deliver better treatment. But administrators see it as a business problem because radiation is a profit center that helps subsidize other areas such as research.

If patients are sold on proton treatment, not available in their hometowns, they have to stay and pay at M.D. Anderson, which means more money for the hospital.

M.D. Anderson officials estimate that when patients on all types of insurance and payment plans are mixed together, proton delivery will cost an average of $37,000 per patient for prostate treatment, compared with $29,000 for IMRT and $21,000 for standard radiation. The amount excludes doctor fees, which will be roughly the same for each.

One insurance payer is Medicare, which publishes its reimbursement rates. It pays $132 for each daily dose of conventional radiation, multiplied by the number of doses needed. It pays $308 for a dose of IMRT and $850 for protons — more than six times conventional treatment.

Inviting venture capitalists

The proton center expects to gross about $100 million annually by its seventh year. Mendelsohn said he always worries about driving up the cost of health care but that Americans expect aggressive treatment of their illnesses.

"I don't think these prices are out of line with what's going on in chemotherapy," he said.

Proton therapy in Texas was not M.D. Anderson's idea.

Massachusetts General had a proton center on the East Coast. Loma Linda had one on the West Coast. In 1997, Tenet Healthcare Corp. approached M.D. Anderson about investing in a proton-therapy center in Dallas. M.D. Anderson was interested but wanted to make sure that if any proton center was built in the state, it was physically attached to its Houston campus.

Tenet later backed out, and Dan Fontaine, senior vice president for business development, said he didn't think he could commit so much state money to a single department. So in late 2000, Fontaine decided the answer was to invite the attention of venture capitalists.

M.D. Anderson chose Sanders Morris Harris of Houston, one of the largest investment-banking firms in Texas, to put the complex deal together.

Though the center will say "M.D. Anderson," which is a part of the state university system, it will be a private, for-profit company that leases M.D. Anderson's name and uses its doctors. All patients will be referred from M.D. Anderson's main facility.

Here is a summary of the confidential investor prospectus and other documents obtained by the Chronicle:

The Houston Proton Therapy Center is owned by a limited partnership whose members have contributed about $30 million. The largest single investor, at $10 million, is the Houston Police Officers' Pension System.

Next comes a roughly $9 million sub-partnership of a few dozen prominent local residents and companies including Nolan Ryan, a subsidiary of Landry's Restaurants and Rich Kinder of Kinder Morgan.

Sanders Morris Harris requested that names of sub-partners not be disclosed and that any article clarify that it did not release the names.

The rest of the limited partners include Sanders Morris Harris, M.D. Anderson itself and some equipment vendors to the center, all of which put in between $1 million and $4 million. M.D. Anderson put in $2.5 million but got it back immediately in return for a 60-year lease of state-owned land for the center.

Higher profits possible

A company co-owned by Sanders Morris Harris and The Styles Company, a hospital developer supervising construction, will manage the center as general partner.

Even with all that cash, the deal still has significant debt. The Houston Firefighters' Relief & Retirement Fund has loaned $27 million as a mortgage. Hitachi, which is building the massive particle accelerator, has made a $50 million equipment loan.

In future years, once the limited partners have recouped their investment plus interest, profits get distributed according to a formula. M.D. Anderson gets 15 percent, but if the center achieves the high return it projects — 58 percent — M.D. Anderson gets up to 25 percent.

It could be a federal anti-kickback violation for a doctor or institution to receive incentive for medical referrals if Medicare or Medicaid is among the insurers, but attorneys said they carefully reviewed the arrangement. At issue would be M.D. Anderson getting a greater profit when the center itself is more profitable, which might appear to be an incentive for M.D. Anderson to send as many patients as possible into the program.

Bruce McMaken, managing partner of Sanders Morris Harris, said attorneys found the contract to be in compliance with the law. The financial incentive will be for staff at the center to efficiently treat patients to squeeze more in a day, not refer more, he said.

M.D. Anderson officials also said it made no financial sense for the doctors — who are on a straight salary — to push patients to the proton center if they didn't feel it was medically advisable. M.D. Anderson merely gets a percentage of the profit at the proton center, compared with all of the profit if it keeps a patient in conventional treatment.

'We pioneered here'

Fontaine said he doesn't think it was such a bad thing that investor money was at risk instead of University of Texas dollars.

"We pioneered here, OK?" Fontaine said. "We pioneered in the business structure and the cancer treatment. Any time you pioneer, there's never a clear road map"

But Ana Iltis, a professor at the St. Louis University Center for Health Care Ethics, questioned the for-profit arrangement of encouraging patients to seek protons, perhaps beyond what medicine has proven advantageous.

"It seems like you're answering two questions simultaneously. We wonder whether this is good, and we're going to tell you it's good and you should come and do it — all at the same time. Whereas, those things should be in sequence," Iltis said.

"What happens in medicine, basically, is that people see opportunities. We have a free market," said Alan B. Cohen, executive director of the Boston University Health Policy Institute.

"There's a new technology that comes on board. And really what prevails is sort of the law of the jungle in terms of whether the technology can make the case that it is superior to some existing technology," said Cohen, co-author of the 2004 book Technology in American Health Care .

Seven proton centers are under construction or in the planning stages across the country, said Leonard Arzt, executive director of the National Association for Proton Therapy. Cohen compared it to an arms race.

"The broader question of what's best for society and if that's a good use of money," he said. "That is a social, political, moral and ethical question that right now there is no single entity in this country to make that decision"